Atrial Fibrillation

A 27-year-old woman with hypertension, type 1 diabetes mellitus, and end-stage renal disease presents to an outpatient renal clinic complaining of generalized weakness. She missed her last dialysis session 2 days earlier.

Survivors of childhood cancer frequently present to primary care practitioners for a routine physical examination or for urgent care. Knowledge of the patient's cancer history and of the specifics of the treatment are essential to providing proper care and addressing his or her unique risks.

The morning after an 88-year-old woman with symptomatic second-degree type I (Wenckebach) atrioventricular block underwent placement of a dual chamber pacemaker without complication, she awoke with uncomfortable pulsations in her abdomen. The pacing thresholds and impedance had remained unchanged since implantation.

My patient is a man in his early 70s who complains of lack of strength. His testosterone level is low, and his B12 level is low-normal.

At what blood pressure is it prudent to treat newly diagnosed hypertension with 2 antihypertensive agents, and what criteria should guide selection of the 2 drugs?

Two days before a 72-year-old woman is admitted to the cardiac care unit (CCU), she had substernal discomfort she described as "heartburn," accompanied by episodes of nausea and vomiting. She attributed her symptoms to GI upset.

A 65-year-old woman with a history of alcohol abuse, hospitalized because of acute pancreatitis, had had petechial hemorrhages on her legs for the past 3 months.

Under what circumstances is it worthwhile to measure aldosterone levels in hypertensive patients? An increasing number of cardiovascular risk factors are being packaged into individual "epidemics."

After a family argument, an 83-year-old woman experienced chest pain, a "racing heart," and a choking sensation and was brought to the emergency department. The chest pain lasted 10 to 15 minutes; was sharp, substernal, and nonradiating; and was associated with dyspnea and a bout of emesis. A sublingual nitroglycerin tablet partially alleviated the pain, but the patient felt syncopal. Her symptoms persisted despite the administration of supplemental oxygen and a second sublingual nitroglycerin tablet. The patient had a history of gastroesophageal reflux disease, allergic rhinitis, and osteoarthritis. Her oral medications included esomeprazole (40 mg/d), aspirin (81 mg/d), and fluticasone nasal spray. She had discontinued valdecoxib 3 weeks earlier.

A 26-year-old white man had blurred vision for 4 weeks. A sluggish light reflex was noted in the left eye. Funduscopic examination showed left-sided optic disc swelling with dot hemorrhages and hard exudates.

I recommend obtaining an ECG in any older patient whose heart rate is more than 100 beats per minute on several occasions. Although it is easy to chalk up such findings to "nerves," "white coat phenomenon," or a morning cup of coffee, I have caught a few cases of asymptomatic atrial fibrillation this way.

A previously healthy 21-year-old man presented with high fever, cough, and pleuritic chest pain. His illness began 6 days earlier with a sore throat that was followed by worsening dyspnea.

How effective is upper airway surgery in treating obstructive sleep apnea? The fallout from the growing obesity epidemic includes obstructive sleep apnea (OSA) syndrome. Although OSA may be considered a "specialty disease" (managed by pulmonologists, sleep specialists, otolaryngologists, and bariatric surgeons), the primary care physician bears the brunt of providing ongoing care.

Each year about 700,000 Americans sustain a stroke, and about 29% of those patients who are aged 65 years or older die within 1 year. Worldwide, stroke is the third leading cause of death and the leading cause of severe disability in adults.

Systolic hypertension is an independent risk factor for coronary artery disease, stroke, and end-stage renal disease. Nonpharmacological interventions for systolic hypertension include limitation of dietary sodium and alcohol intake along with weight reduction and aerobic exercise.

A 22-year-old woman has had chronic nausea, emesis with green vomitus, and diarrhea for the past 10 months. The diarrhea is frequent (about 3 to 8 times daily) and does not resolve with starvation.

In the vast majority of nonsmokers who are not receiving angiotensin converting-enzyme inhibitors and who have no evidence of active disease on chest radiographs, chronic cough is caused by postnasal drip syndrome (recently renamed upper airway cough syndrome [UACS]), asthma, non-asthmatic eosinophilic bronchitis, or gastroesophageal reflux disease (GERD), alone or in combination.

A 57-year-old woman presents for follow-up several months after a series of thrombotic episodes. Four days after she underwent ankle fusion to relieve pain and edema associated with a leg fracture that had occurred 40 years earlier, she sustained a massive myocardial infarction (MI).

An obese 61-year-old man with a history of heroin abuse was brought to the hospital after he had fallen onto his buttocks on a sidewalk. He was able to stand initially, but weakness and numb-ness in his legs rendered him suddenly unable to walk or prevent himself from voiding. He denied abdominal or back pain. His medical history included asthma, chronic obstructive pulmonary disease, and hypertension.

As a busy internist who tries to keep up with current literature, I have always been dismayed at the general acceptance and even promotion of published practice guidelines by the scientific community.

A 62-year-old man presents with painful cramps in his left lower leg that began about 6 months earlier and have recently become more frequent. The cramps occur with vigorous walking and cease when he stops for several minutes.

Nephropathy develops in about 30% of patients with diabetes. Screen for albuminuria at the time type 2 diabetes is diagnosed and within 5 years of diagnosis of type 1 diabetes.

During the first quarter of a football game, a 17-year-old athlete noticed that his right (dominant) arm was swollen and heavy. Two days earlier, he had fired a shotgun right-handed multiple times while hunting.

When angiotensin-converting enzyme (ACE) inhibitors were first discovered, they were a welcome addition to the antihypertensive armamentarium. Since then, many more benefits of these drugs have been found: they slow the progression of diabetic nephropathy, abate the sequelae of heart failure when systolic dysfunction is present, and reduce the level of proteinuria in patients with nephrotic syndrome.

Acute abdominal pain, fever, and chills prompted a 51-year-old man to visit his local hospital twice in one week. On both visits, a clinical and laboratory workup was negative. He then presented to a tertiary care center with worsening symptoms. His history included hypertension and tobacco and alcohol use.

A 44-year-old man presented to the emergency department (ED) with pain and swelling of the left ankle and a petechial rash in the pretibial area that developed the night before. He also reported "fluttering" in his chest.

A 75-year-old man is concerned about the discoloration of his fingernails: each nail has dark bands with a clearing in the middle.

Despite meticulous titration of anticoagulation therapy and careful attention to confounding medications, serious bleeding complications occur in some patients who receive warfarin.

The differential diagnosis of generalized weakness is enormous; it includes disorders at all levels of the neur-axis. A variety of electrophysiological, pathological, radiographic, and other laboratory studies may be indicated depending on the specific diagnostic possibilities; costs can be controlled if such investigations are selected judiciously.

Treatment of hypertension can minimize both microvascular and macrovascular complications of diabetes and helps prevent nephropathy and cardiovascular events.